Provider Demographics
NPI:1316053408
Name:KHAN, NUSRAT ALI (MD)
Entity type:Individual
Prefix:DR
First Name:NUSRAT
Middle Name:ALI
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1313
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-1313
Mailing Address - Country:US
Mailing Address - Phone:817-374-4949
Mailing Address - Fax:
Practice Address - Street 1:5077 E INTERSTATE 20 SERVICE RD N
Practice Address - Street 2:
Practice Address - City:WILLOW PARK
Practice Address - State:TX
Practice Address - Zip Code:76087-3219
Practice Address - Country:US
Practice Address - Phone:817-374-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5284208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2176497-01Medicaid
TX8F5259OtherMEDICARE PROVIDER NUMBER
TX8F5259Medicare PIN
TX2176497-01Medicaid